Copyright B 2018 Wolters Kluwer Health, Inc. All rights reserved.

Elaine Wittenberg, PhD

Betty Ferrell, PhD, MA, RN, FAAN, FPCN, CHPN
Marianna Koczywas, MD
Catherine Del Ferraro, MSN, Ed, PHN, RN, CCRP
Nora H. Ruel, MA
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Pilot Study of a Communication Coaching

Telephone Intervention for Lung
Cancer Caregivers
K E Y W O R D S Background: Family caregivers are a key communication source for nurses, and
Cancer there is a need to provide communication skill building for caregivers. Objective:
Coaching A pilot study was conducted to determine feasibility and use of a communication
Communication coaching telephone intervention aimed at improving caregiver confidence in
Family caregiver communication and reducing psychological distress. Methods: A printed
Lung cancer communication guide for caregivers and a 1-time communication coaching call
delivered by a research nurse were provided to caregivers. Recruitment and attrition,
implementation and content of coaching calls, caregiver outcomes, and satisfaction
with intervention were analyzed. Results: Twenty caregivers were recruited across
4 cohortsVdiagnosis, treatment, survivorship, and end of lifeVwith recruitment
greater than 70%. Caregiver calls averaged 37minutes, and most caregivers reported
communication challenges with family members. Caregiver action plans revealed
a need to develop communication skills to ask for help and share information.
Caregivers reported satisfaction with the print guide, and 90% of caregivers followed
through with their action plan, with 80% reporting that the action plan worked.
Caregiver confidence in communication with healthcare providers was improved,
except for caregivers of cancer survivors. Conclusions: Recruitment and attrition
rates demonstrate feasibility of the intervention. Caregivers reported that the
communication coaching telephone intervention was considered valuable and they

Author Affiliations: Divisions of Nursing Research and Education
(Drs Wittenberg and Ferrell and Ms Del Ferraro), Medical Oncology (Dr
Koczywas), and Biostatistics (Ms Ruel), City of Hope National Medical Center,
Duarte, California.
Research reported in this publication was supported by the National Cancer
Institute of the National Institutes of Health under award number
P30CA33572. The content is solely the responsibility of the authors and does
not necessarily represent the official views of the National Institutes of Health.
The authors have no conflicts of interest to disclose.
Correspondence: Elaine Wittenberg, PhD, Division of Nursing Research
and Education, City of Hope National Medical Center, 1500 E Duarte Rd,
Duarte, CA 91010 (ewittenberg@coh.org).
Accepted for publication June 7, 2017.
DOI: 10.1097/NCC.0000000000000535

506 n Cancer Nursing , Vol. 41, No. 6, 2018

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Wittenberg et al

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

 were able to implement a communication action plan with others. Implications for
Practice: Lessons were learned about intervention content, namely, that nurses can
help caregivers learn communication strategies for asking for help, sharing cancer
information, and initiating self-care.
C
urrently, interventions for family caregivers do not spe-
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cifically target communication skill building to support
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the caregiver"s communication role and improve care-
giver confidence in communication with patient, family, and
healthcare providers. However, interventions with communica-
tion skill training have shown to be an option with good results.
A recent study found that a family-oriented communication
skill training program for older adults reduced depression, anx-
iety, and stress.1 Developing the confidence of caregivers to
communicate with others about cancer is a key caregiving skill,2
and interventions to develop caregiver communication skills
are needed.
Although telephone coaching is not novel in cancer inter-
vention research, most interventions have been based on prob-
lems identified by researchers rather than tailored to the unique
needs of patients.3 In addition, coaching interventions have
been primarily offered to patients with cancer and cancer sur-
vivors and have not included family caregivers. There is a vital
need for lung cancer caregivers, in particular, to develop confi-
dence in communication because they report feeling responsible
for the psychological well-being of the patient4 and attempt to
protect the patient and maintain hope by avoiding discussions
about the diagnosis and illness trajectory.5 The desire to protect
each other results in topic avoidance between caregiver and
patient, impacting communication with other family members
and healthcare providers. In the absence of open communica-
tion, caregiver depression results from low-quality relationships
among family members, a lack of emotion from the patient,
and greater conflict.6 Communication constraints can be a barrier
to quality care7 and potentially influence caregiver distress. This
study explored the feasibility and use of a nurse-delivered com-
munication coaching telephone intervention specifically designed
to improve caregiver confidence in communication and reduce
psychological distress by supporting caregivers in their commu-
nication about cancer with others.
Theoretical Framework
The Cancer Family Caregiver Experience8 framework outlines
context, primary stressors, appraisal of caregiving, and second-
ary stressors as antecedents of caregivers and patients" health
and well-being. The framework depicts that family caregivers
manage caregiving within a family system, which influences
secondary stressors (family communication patterns about ill-
ness that reveal role changes, changes in family structure, life-
style changes as a result of illness) and shapes their cognitive/
behavioral responses (communication apprehension), ultimately
impacting both caregiver and patient health and well-being.
Previous research on caregiver stress and coping has determined
that communication is a central part of the stress process model
Communication Coaching for Caregivers
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
because communication is 1 way caregivers manage interper-
sonal challenges, especially in communicating emotions.9
Using this framework, we designed a nurse-delivered com-
munication coaching telephone intervention to provide knowl-
edge and skill building to help caregivers develop positive appraisals
of caregivers through preparedness and to strengthen the coping
process by improving communication with patient, family, and
healthcare providers. The caregiver"s communication skills may
be an intervening variable that explains the relationship between
2 variables of the stress process leading to better outcomes.
n Methods
The pilot study was conducted at a comprehensive cancer center
in the western United States. The study was approved by the
cancer center"s institutional review board (#15359), and written
consent was obtained.
Intervention
The intervention consisted of a print copy of A Communication
Guide for Caregivers10 and a nurse-delivered communication
coaching telephone call. The guide has 4 sections for caregiver
communication with the patient, local family, family who are
far away, and healthcare providers. Each section identifies com-
munication challenges, example language, questions for reflec-
tion, questions to ask providers, and ways to share information
with others. Development of the guide has been described else-
where,11 and Table 1 shows the table of contents. The guide is
written at the sixth grade level and meets health literacy standards.
Caregivers have previously reported that content is relatable,
useful, and easy to read. Healthcare providers have also rated the
material as easy to understand and use for patients/family mem-
bers of diverse backgrounds and varying levels of literacy.
Although coaching interventions are typically conducted
longitudinally, a 1-time call was initially tested in this pilot study
to confirm caregiver acceptance of communication skill build-
ing and because telephone-based coaching is an effective format
for caregiver interventions that ensures flexibility and adaptabil-
ity.12 Table 2 shows an overview of the content of the inter-
vention coaching call. The research nurse attended a 2-day
communication training course to develop communication
coaching skills, which included instruction on family caregiver
communication characteristics, active listening skills, and how
the nurse can use open-ended questions to meet the caregiver"s
communication style. The principal investigator of the study
also met with the research nurse weekly to discuss study protocol,
provide feedback on coaching calls, and review data.
Cancer NursingA, Vol. 41, No. 6, 2018 n 507

Table 1 & Overview of Contents for A
Communication Guide for Caregivers
Table of Contents
Section 1& Communication with the patient
How do I take care of someone with cancer?
What should I care with the patient/family member?
What if we don"t agree?
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Section 2& Communication with other family member
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Who is family?
How do I talk about cancer with my family?
Why is talking about cancer difficult?
How can my family help me?
Section3& Communication with family members who are far away
What is it like to be a family member far away?
What does the cancer journey look like?
Section 4& Communication with healthcare providers
What do healthcare providers need from me?
What can I ask a healthcare provider?
What if I can"t do what is asked?
Participants
Eligibility criteria included 18years or older, English speaking,
and being a primary family caregiver as identified by the patient
with lung cancer. Five caregivers were recruited in each cohort
based on the cancer care continuum: cohort 1, diagnosis (patient
diagnosis was received within the last 45days but had not yet
started treatment); cohort 2, treatment (patient started initial
treatment within the last 30days with prognosis of more than
1year); cohort 3, survivorship (patient had completed treatment
and was clinically disease free at the time of caregiver enrol-
ment); and cohort 4, end of life (patient was estimated to have
6months or less to live).
Intervention Implementation
Patients receiving outpatient care were screened by the oncol-
ogist and research nurse to identify potential caregivers in each
cohort. Cohort eligibility was confirmed via medical records and
oncologist consultation. Eligible caregivers were approached in
the clinic, and written consent was obtained. Caregivers who
received the intervention were given a copy of the guide upon
consent and participated in a communication coaching call sched-
uled 1week from study consent. Communication coaching calls
were audio-recorded and transcribed.
Caregiver Outcomes
All caregivers completed baseline and follow-up measures of
psychological distress and caregiver confidence in communi-
cation by telephone 1month after the coaching call. The psy-
chological distress thermometer is an efficient tool to evaluate
caregiver distress for the past week, based on a scale of 0 to 10,
and is included in the National Comprehensive Cancer Network
Psychological Distress guidelines.13 A score of 5 or higher in-
dicates a need for intervention,14 and appropriate support referrals
508 n Cancer Nursing , Vol. 41, No. 6, 2018
A
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
are made, such as social work services, pastoral counseling,
and psychological treatment.15 The distress thermometer has a
sensitivity of ! =.87 and a specificity of ! =.72 for detecting
clinical levels of distress.14,16
The caregiver confidence in communication survey was de-
veloped by the research team for this study to measure caregivers"
confidence communicating with patient, family members, and
healthcare providers across 4 specific topic areas (cancer diag-
nosis, cancer treatment and goal of treatment, symptom manage-
ment including managing pain and adverse effects, and broader
life topics such as spirituality and stress from caregiving). Care-
givers rated their communication confidence using a Likert scale
rating from 0 (‘‘not confident’’) to 10 (‘‘very confident’’).
Finally, the research nurse conducted a brief telephone inter-
view with the caregiver regarding intervention satisfaction at
1month. Caregivers were asked to report how satisfied they were
with the printed guide, how prepared they felt to carry out their
action plan, whether they carried out the action plan, and
whether the action plan worked.
Data Analysis
Transcripts from the coaching calls and satisfaction interviews
were analyzed using content analysis, and demographic data
were summarized. The Wilcoxon rank sum test was used to
compare baseline and postintervention metrics for each cohort.
n Results
Recruitment and Attrition
Thirty-two caregivers were approached, and 72% of the eligible
caregivers consented (n=23). Six caregivers declined study par-
ticipation because of lack of interest, two reported that they were
too busy, and one declined because of health reasons. Three
Table 2 & Communication Coaching Telephone
Intervention
Question
Who is the most challenging to talk to about cancer?
Probe: patient, family members, or healthcare providers
What is most challenging for you to talk about?
Probe: what barriers keep you from communicating better?
Probe: what is happening that makes communication difficult?
When you think about having to talk about cancer and you
know it will be challenging, how does this impact you?
Probe: physically? Psychologically? Socially? Spiritually?
Let"s review the guide and select a strategy that may work in this
situation or select an exercise.
Let"s develop a personal action plan for you to improve the
communication you have described as challenging.
Let"s role-play the potential solution to the communication
challenge we have been talking about.
Finally, I"d like to briefly identify other pages in the guide that
may be useful to you.
Wittenberg et al
 caregivers were lost to attrition across cohorts because of lack
of interest (cohort 4, end of life), nonresponse (cohort 3,
survivorship), and declining patient health (cohort 1, diagnosis).
The mean age of caregivers was 56.1years. Most caregivers were
white (80%), female (70%), and college level educated (75%).
Most caregivers were spouses/partners (65%).
Implementing Coaching Calls
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Communication coaching calls averaged 37minutes (range,
11-85 minutes). Although all consenting caregivers completed
the communication coaching call, there was difficulty schedul-
ing the calls due to caregiver availability. Overall, 8 caregivers
completed the communication coaching within 1week from
consent. On average, calls took place within 2weeks. One care-
giver from cohort 4 (end of life) did not complete the com-
munication coaching until 54days after consent.
Only half of the caregivers participated in role-play during
the call. Caregivers were reluctant to try role-playing their com-
munication challenge with the research nurse. In many cases,
caregivers only wanted to talk in general about communication
approaches rather than try a new communication strategy. Care-
givers politely avoided role-play with the nurse by explaining that
there were other people available for support, talking in general
about how to use the communication strategy, or focusing on
how their self-care needs were being met. The following are
some examples:
& In 1 instance, a caregiver focused on ways to be present with the
patient and initiated a discussion about nonverbal communi-
cation and ways she could communicate respect to the patient.
& When the nurse attempted to role-play ways to share infor-
mation with a child, the caregiver responded by talking in
general about the many topics to cover in the conversation.
& After identifying the need for self-care, including a physical
examination, the caregiver deflected an attempt to role-play by
explaining that her husband, sister, and brother-in-law support
all of her caregiving efforts.
Reported Challenges During Calls
Nine caregivers (45%) reported that family was the most chal-
lenging to talk to about cancer, followed by the patient (30%)
and healthcare providers (15%). Two caregivers reported no
communication problems. Family communication challenges
were embedded in previous family experiences, reflecting fears
of loss, fear of causing stress to others, and not knowing how to
initiate conversations or what questions to ask. A caregiver from
cohort 4 (end of life) explains that communication with her
siblings is difficult:
Sometimes they refuse to hear or see above my mom"s
illness or they don"t bother to ask. I have to take the
initiative and make the conversationIand I have to do it
one at a time. I"m not going to talk with all of my
brothers at the same time.
Although most caregivers did not initially identify commu-
nication challenges with healthcare providers, coaching calls
Communication Coaching for Caregivers
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
often detailed the caregiver"s self-described inability to commu-
nicate with providers caused by nervousness, a desire to avoid
certain conversations, daunting medical jargon, fast-paced con-
versations, language barriers, and not knowing what questions
to ask. When asked who was most difficult to talk with, one
caregiver responded: ‘‘I would say probably the healthcare pro-
vider just becauseIIt"s not her, it"s me. The inability to com-
municate. I"ve always had a hard time.’’
Patient communication challenges were less frequent in
coaching call discussions and focused almost exclusively on fear
of discussing the future and frustration with cognitive decline.
A caregiver from cohort 1 (newly diagnosed) shared that her
number 1 communication challenge was ‘‘the nervousness and
communicating about the disease and my mother and then not
wanting to go in certain directions with the conversations.’’
Caregiver Action Plans
During the coaching call, caregivers worked with the research
nurse to develop a personal action plan based on a self-identified
communication challenge. On the basis of the caregiver"s unique
circumstances, the research nurse identified strategies in the
communication guide to assist the caregiver in developing an
action plan for communicating with others. Caregiver action
plans varied, and there were 4 main challenges present across all
caregiver action plans: asking others for help or to do something
specific, sharing information about cancer with family members,
being present for the patient, and initiating self-care. Table 3
provides a summary of caregiver action plans by themes.
Caregiver Outcomes
A comparison of mean scores showed improvement in caregiver
confidence in communication across caregivers in each cohort
except for the survivorship cohort (Table 4). Combined results
from all 4 cohorts showed statistically significant improvement
in confidence with healthcare providers (P=.01). The average
decline in stress was 0.09 on the distress thermometer; however,
caregivers in cohort 4 (end of life) had increased stress from
baseline (mean, 4.2/10) to 1-month follow-up (mean, 4.8).
Caregiver Satisfaction With Intervention
Caregivers reported that they were very satisfied (60%) and
somewhat satisfied (25%) with the print guide; however, 1 care-
giver described the guide as a painful reminder that his wife
was sick, and 2 caregivers shared that the guide was not useful
for them. ‘‘It was not very helpful. It"s been six years since my
wife"s diagnosis and I have done most of the things suggested
in the guide,’’ explained 1 caregiver in cohort 3 (survivorship).
On the other hand, caregivers in cohort 4 (end of life) found
the guide ‘‘informative, enlightening, and very helpful.’’ One
caregiver explained, ‘‘It helped me understand and accept the
challenges ahead of me.’’ Several caregivers commented that the
guide was easy to read, yet they found it ‘‘too simplistic’’ and
‘‘too generalized,’’ desiring more information specific to their
family situation. Table 5 outlines caregiver satisfaction with the
Cancer NursingA, Vol. 41, No. 6, 2018 n 509
 Table 3 & Examples of Caregiver Action Plans
Asking others
& When uncle offers to watch her child, caregiver will ask him to watch the patient so she can spend time with her child. She plans to
communicate that sitting with the patient while she ran errands with her daughter would be more helpful.
& Asking son and daughter to stay with the patient so caregiver can attend a 3-day conference
& Ask the patient to have family game night on Fridays again to stimulate family conversation and communication
& Ask doctor to slow down when communicating
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& Ask husband for help with children so she can better attend to patient"s needs
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& Ask father"s sister to help by coming on Sundays to visit with mother (patient) so caregiver can spend quality time with her husband
Sharing information
& Caregiver will share her need for help and support with daughter.
& Strategies for sharing information with stepfather regarding patient"s chemotherapy treatment
& Caregiver will tell in-laws that he believes holistic modalities are not realistic for the patient.
& Caregiver will tell sister-in-law that her brother was given a diagnosis of cancer.
Being present
& When the patient isolates herself by sitting away from family, caregiver will engage in nonverbal communication strategies to ‘‘be present’’ with
the patient.
& Recognizing when something is different with the patient
Initiating and reinforcing self-care
& Continue to improve and maintain her self-care needs
& Schedule a doctor"s appointment for routine examination
& Realization that yearly physical examination has not been conducted
& Caregiver realizes during call that she has been crying alone and needs to talk about stress of caregiving

intervention by cohort. Caregivers from all cohorts reported
feeling generally prepared, and 90% of the caregivers followed
through with their action plan, with 80% reporting that the
action plan worked. ‘‘I have better tools in my toolboxI. I feel
confident,’’ shared 1 caregiver.
n Discussion
This is the first study to evaluate the feasibility of a commu-
nication coaching telephone intervention developed for family
caregivers of patients with lung cancer using a tailored approach
that allows caregivers to identify communication challenges.
Recruitment in an outpatient cancer care clinic was successful,
and the enrolled-to-consent rate of caregivers was similar to
other nurse-led intervention research,17 averaging more than
70%. Recruitment with the support of the oncologist was
effective and needs to be considered for a larger trial.
There are several implications for intervention delivery in
a future randomized controlled trial. For example, caregivers
were reluctant to participate in role-play during the call. Care-
giver discomfort with role-playing a scenario with the nurse indi-
cates that intervention content may need revision, such as focusing
more on reviewing communication skills in the print guide.
Although role-play activities have been shown to be an ef-
fective teaching tool for communication skill building in health-
care provider training,18Y20 this study suggests that role-play
may not be an appropriate communication skill building activity
for caregivers. A future trial would need to consider ways to
discuss what the caregiver might say rather than attempting a
formal role-play with the nurse. Scheduling coaching calls with
caregivers also proved to be challenging, with a 1-week expected
time frame from consent to scheduled call difficult for caregivers
to achieve. This pilot study demonstrates that 2weeks is more
appropriate. Providing availability of the guide in digital format
may also increase the flexibility of the intervention study design.
In line with patient with lung cancer and caregiver preferences
for intervention delivery, the telephone intervention was ac-
ceptable.21 As more and more supportive care is being de-
livered to caregivers by telephone and caregivers also desire more

Table 4 & Summary of Mean Scores by Cancer Care Continuum

Diagnosis Treatment Survivorship End of Life
Base FU Base FU Base FU Base FU
Caregiver confidence communicating witha:
Patient 7.7 8.6 7.7 8.6 9.3 9.2 8.1 7.2
Family 7.8 8.9 7.2 8.0 8.7 8.6 7.6 7.9
Healthcare provider 7.1 9.5 8.3 9.2 9.0 8.0 7.8 8.8
Psychological distressb 5.6 2.8 4.2 3.6 2.4 1.6 4.2 4.8

Abbreviations: Base, baseline; FU, follow-up.

a
Scale of 0 (‘‘not confident’’) to 10 (‘‘very confident’’).
b
Scale of 0 to 10, with 5 or more indicating a need for intervention.

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 Table 5 & Caregiver Satisfaction With Intervention
Cohort 1,
Diagnosis (N = 5)
Satisfaction with printed guide, n (%)
Very satisfied 4 (80)
Somewhat satisfied 1 (20)
Neutral 0 0
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Somewhat dissatisfied 0 1 (20)
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How prepared, n (%)
Very prepared 3 (60)
Somewhat prepared 2 (40)
Neutral 0 1 (20)
Follow-through with action plan, n (%)
Yes 5 (100)
No
Did action plan work, n (%)
Yes 5 (100)
No 0 0
support by telephone, there is a need for both clinicians and
research personnel to develop better telephone skills to improve
interactions with caregivers.
Similar to other lung cancer caregiving research,4,22 this pilot
study found that common communication challenges experi-
enced by caregivers occur with family members. Caregivers
predominantly identified family as the most challenging to talk
to about cancer, and their action plans centered on commu-
nication skills with family members. Overall, there was less
importance placed on caregiver-patient communication during
coaching calls and within action plans, suggesting that future
communication interventions should concentrate on caregiver
skills with providers and/or family members.
This study highlights 4 key areas for communication skill
development for lung cancer caregivers. First, caregivers need to
learn effective ways to ask for help from others in a manner that
makes them feel comfortable. Information and healthcare ser-
vices remain among the top unmet supportive care needs of lung
cancer caregivers, and healthcare service needs are associated
with caregivers" fatigue.23 Second, caregivers need tools for how
to share information with others about the patient’s cancer.
The ability and willingness to share information about cancer
have been shown to improve the patient"s quality of life24 and
may have a similar effect on caregivers. Future research should
explore the impact of information sharing on caregivers because
recent research has found that complicated grief symptoms are
higher among families with family members who had difficulty
accepting the illness.7 For example, the use of communication
facilitators (trained nurses and social workers) to support com-
munication between clinicians and families in the intensive
care unit has been shown to reduce family distress.25 Third,
caregivers need to learn how to be present for the patient by
recognizing specific nonverbal behaviors that can indicate poor
psychological well-being. Fourth, caregivers need encourage-
ment to recognize and initiate self-care. Action plans developed
by caregivers in this study demonstrated that talking about
caregiving prompted thinking about self-care needs. More
Communication Coaching for Caregivers
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Cohort 2, Cohort 3, Cohort 4, End
Treatment (N = 5) Survivorship (N = 5) of Life (N = 5)
4 (80) 1 (20) 3 (60)
0 3 (60) 1 (20)
1 (20) 1 (20)
0 0
3 (60) 4 (80) 4 (80)
1 (20) 1 (20) 1 (20)
0 0
5 (100) 4 (80) 4 (80)
1 (20) 1 (20)
3 (60) 4 (80) 4 (80)
1 (20) 1 (20)
research on caregiver communication skill and ability and
impact on quality of life are warranted.
A recent qualitative study with patients with lung cancer and
caregivers revealed a desire for educational interventions that
focus on adverse effects and the provision of various coping
skills.21 Similarly, in a palliative care intervention study for
lung cancer caregivers, which had a significantly positive impact
on caregiver quality of life, symptom management strategies
were a top priority across the 4 educational sessions of the quality-
of-life intervention.26 Findings in this pilot study suggest that
caregiver education should include attention to communi-
cation skills to combine both knowledge needs for symptom
management and communication skills to aid in coping with
symptom management responsibilities. It has been surmised
that coaching builds confidence by reinforcing the participants"
efficacy expectation, and confidence in communication can
therefore be improved by creating an awareness of one"s own
communication approach and style.27 This may account for the
disparity between the content of the action plans developed by
caregivers, which centered on family communication, and out-
come results showing improved caregiver confidence with health-
care providers about the patient"s treatment and adverse effects.
The tailored intervention approach, which allowed caregivers
to self-identify a communication challenge for the coaching
call, suggests that these skills are applicable to others. Further
research is required to formally evaluate the impact of caregiver
communication coaching on communication in clinical visits
with providers and patient outcomes.
Recruitment strategies developed for future work should
target caregivers of patients who are newly given a diagnosis,
undergoing treatment, or at the end of life. Although there is
a need to improve patient-centered communication between
healthcare providers and cancer survivors,28 this intervention
did not result in improved caregiver confidence in communi-
cation for caregivers of cancer survivors. Still, the 1-time com-
munication skill development session with a research nurse
resulted in a communication action plan that could be carried
Cancer NursingA, Vol. 41, No. 6, 2018 n 511
 out by the caregiver. Furthermore, distress may be the wrong
outcome variable to assess study effectiveness.
This study was limited by the use of a small and select
sample; thus, observed differences among the cohorts may not
be meaningful. Although natural improvements to caregiver
outcomes may occur over time irrespective of the intervention,
statistically significant improvements are not common in small
sample sizes. Notably, caregivers in the study were primarily
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white and college educated, and the study is thus limited by a
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lack of cultural diversity. Further research is needed to explore
how communication difficulties vary among other races and
with lower educational levels. Given that the guide is written at a
low literacy level and most caregivers in this sample were college
educated, there is a need to evaluate the intervention with
caregivers with low education and nonYEnglish-speaking back-
grounds. Finally, although caregivers were able to carry out their
action plan, results of the action plans remain unknown, and
communication barriers may be culturally linked.
As family caregivers increasingly become clinician partners
in oncology care, nurses are challenged to prepare family care-
givers for their role. This study has captured the important role
of family caregivers in cancer care and illustrates the need to
provide support as caregivers face communication difficulties
related to caregiving tasks and decision-making. Key implica-
tions for nursing practice include the need to assess for com-
munication between family caregivers, patients, and other
members of the family. Identifying caregivers who may benefit
from communication coaching is vital to ensure caregiver involve-
ment in cancer care. This study demonstrates that a 1-time
telephone coaching intervention can help caregivers with com-
munication challenges. Including communication skill building
as part of caregiver support is important because caregiver con-
cerns vary over time. The nurse"s ability to support caregivers is
essential to quality cancer care, including teaching caregivers
how to ask for help, how to share information with others, how
to recognize patient nonverbal behavior, and how to convey the
need for self-care.
References
1. Ghazavi Z, Feshangchi S, Alavi M, Keshvari M. Effect of a family-
oriented communication skills training program on depression, anxiety,
and stress in older adults: a randomized clinical trial. Nurs Midwifery Stud.
2016;5(1):e28550.
2. Yuen EY, Dodson S, Batterham RW, Knight T, Chirgwin J, Livingston PM.
Development of a conceptual model of cancer caregiver health literacy. Eur
J Cancer Care (Engl). 2015;25(2):294Y306.
3. Howard-Jones AR, Isaacs D. Systematic review of duration and choice of
systemic antibiotic therapy for acute haematogenous bacterial osteomyelitis
in children. J Paediatr Child Health. 2013;49(9):760Y768.
4. Mosher CE, Jaynes HA, Hanna N, Ostroff JS. Distressed family caregivers
of lung cancer patients: an examination of psychosocial and practical
challenges. Support Care Cancer. 2013;21(2):431Y437.
5. Caughlin JP, Mikucki-Enyart S, Middelton A, Stone A, Brown L. Being
open without talking about it: a rhetorical/normative approach to under-
standing topic avoidance in families after a lung cancer diagnosis. Commun
Monogr. 2011;78(4):409Y436.
6. Siminoff LA, Wilson-Genderson M, Baker S Jr. Depressive symptoms in
lung cancer patients and their family caregivers and the influence of family
environment. Psychooncology. 2010;19(12):1285Y1293.
512 n Cancer Nursing , Vol. 41, No. 6, 2018
A
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
7. Kramer BJ, Kavanaugh M, Trentham-Dietz A, Walsh M, Yonker JA.
Complicated grief symptoms in caregivers of persons with lung cancer:
the role of family conflict, intrapsychic strains, and hospice utilization.
Omega. 2010;62(3):201Y220.
8. Fletcher BS, Miaskowski C, Given B, Schumacher K. The cancer family
caregiving experience: an updated and expanded conceptual model. Eur J
Oncol Nurs. 2012;16(4):387Y398.
9. Stone AM, Mikucki-Enyart S, Middleton A, Caughlin JP, Brown LE.
Caring for a parent with lung cancer: caregivers" perspectives on the role
of communication. Qual Health Res. 2012;22(7):957Y970.
10. The Comfort Communication Project. A communication guide for caregivers.
2016. www.communicatecomfort.com/resources.
11. Wittenberg E, Goldsmith J, Ferrell B, Ragan SL. Promoting improved
family caregiver health literacy: evaluation of caregiver communication
resources. Psychooncology. 2017;26(7):935Y942.
12. Ferrell B, Wittenberg E. A review of family caregiving intervention trials
in oncology. CA Cancer J Clin. 2017;67(4):318Y325.
13. National Comprehensive Cancer Network. Distress: treatment guidelines for
patients. 2014. https://www.nccn.org/about/permissions/thermometer.aspx.
14. Graves KD, Arnold SM, Love CL, Kirsh KL, Moore PG, Passik SD.
Distress screening in a multidisciplinary lung cancer clinic: prevalence
and predictors of clinically significant distress. Lung Cancer. 2007;55(2):
215Y224.
15. National Comprehensive Cancer Network. NCCN practice guidelines
for the management of psychosocial distress. Oncology (Williston Park).
1999;13(5A):113Y147.
16. Jacobsen PB, Donovan KA, Trask PC, et al. Screening for psychologic
distress in ambulatory cancer patients. Cancer. 2005;103(7):1494Y1502.
17. Schenker Y, White D, Rosenzweig M, et al. Care management by
oncology nurses to address palliative care needs: a pilot trial to assess
feasibility, acceptability, and perceived effectiveness of the CONNECT
intervention. J Palliat Med. 2015;18(3):232Y240.
18. Gough JK, Frydenberg AR, Donath SK, Marks MM. Simulated parents:
developing paediatric trainees" skills in giving bad news. J Paediatr Child
Health. 2009;45(3):133Y138.
19. Gough J, Johnson L, Waldron S, Tyler P, Donath S. Clinical communi-
cation: innovative education for graduate nurses in paediatrics. Nurse Educ
Pract. 2009;9(3):209Y214.
20. Fisher MJ, Taylor EA, High PL. Parent-nursing student communication
practice: role-play and learning outcomes. J Nurs Educ. 2012;51(2):
115Y119.
21. Mosher CE, Ott MA, Hanna N, Jalal SI, Champion VL. Development
of a symptom management intervention: qualitative feedback from ad-
vanced lung cancer patients and their family caregivers. Cancer Nurs. 2017;
40(1):66Y75.
22. Mosher CE, Bakas T, Champion VL. Physical health, mental health, and
life changes among family caregivers of patients with lung cancer. Oncol
Nurs Forum. 2013;40(1):53Y61.
23. Chen SC, Chiou SC, Yu CJ, et al. The unmet supportive care needsVwhat
advanced lung cancer patients" caregivers need and related factors. Support
Care Cancer. 2016;24(7):2999Y3009.
24. Lai C, Borrelli B, Ciurluini P, Aceto P. Sharing information about cancer
with one"s family is associated with improved quality of life. Psychooncology.
2016. [Epub ahead of print].
25. Curtis JR, Treece PD, Nielsen EL, et al. Randomized trial of communi-
cation facilitators to reduce family distress and intensity of end-of-life care.
Am J Respir Crit Care Med. 2016;193(2):154Y162.
26. Borneman T, Sun V, Williams AC, et al. Support for patients and family
caregivers in lung cancer: educational components of an interdisciplinary
palliative care intervention. J Hosp Palliat Nurs. 2015;17(4):309Y318.
27. Wagland R, Fenlon D, Tarrant R, Howard-Jones G, Richardson A.
Rebuilding self-confidence after cancer: a feasibility study of life-coaching.
Support Care Cancer. 2015;23(3):651Y659.
28. Blanch-Hartigan D, Chawla N, Moser RP, Finney Rutten LJ, Hesse BW,
Arora NK. Trends in cancer survivors" experience of patient-centered
communication: results from the Health Information National Trends
Survey (HINTS). J Cancer Surviv. 2016;10(6):1067Y1077.
Wittenberg et al